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What health care assistants know about clean hands

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VOL: 97, ISSUE: 22, PAGE NO: 63

Chris Perry, RGN, is senior nurse, infection control, United Bristol Healthcare NHS Trust

Every patient admitted to hospital is at risk of getting an infection, with the most recent UK figures suggesting that the prevalence rate is 9.2% (Emmerson et al, 1996). It is the responsibility of all health care workers to practise in a manner that reduces this risk. Although researchers have investigated the infection control knowledge and practice of registered nurses and nursing students, few studies have focused on health care assistants (HCAs). Basic nursing duties form most of an HCA's role. However, some are undertaking invasive procedures, such as venepuncture. A study was undertaken to find out what they knew about infection control and practice.

Every patient admitted to hospital is at risk of getting an infection, with the most recent UK figures suggesting that the prevalence rate is 9.2% (Emmerson et al, 1996). It is the responsibility of all health care workers to practise in a manner that reduces this risk. Although researchers have investigated the infection control knowledge and practice of registered nurses and nursing students, few studies have focused on health care assistants (HCAs). Basic nursing duties form most of an HCA's role. However, some are undertaking invasive procedures, such as venepuncture. A study was undertaken to find out what they knew about infection control and practice.

Hand-washing
There are a number of basic principles that apply to good infection control practice, but hand-washing is commonly acknowledged as the single most important procedure.

Since there is potential for micro-organisms to be transferred between patients and also from one site to another on the same patient (Bauer et al, 1990), this key principle has been used to assess HCAs' knowledge.

Despite the fact that nursing staff have the appropriate knowledge of hand-washing, Gould and Chamberlain (1997) found that what happened at ward level did not always reflect good practice. This gap between knowledge and practice, often called the 'theory-practice gap', may be exacerbated by the setting where learning takes place.

Nurses learn from their peers in a clinical setting and quickly adapt their practice to what they have seen (Melia, 1987; Morgan, 1996). HCAs appear to learn most of their practice in a clinical setting, and therefore this study assessed both hand-washing practice and knowledge.

Methods
HCAs' knowledge was assessed via a questionnaire, which was distributed to 92 HCAs on general medical and orthopaedic wards, with 38 (41%) questionnaires returned.

The questionnaire was adapted from two previously published studies (Gould and Chamberlain, 1997; Perry and Gore, 1997), with minor alterations made following a small pilot study. The questionnaire assessed HCAs' knowledge of:

- When and how to wash hands;

- How they rated their infection control knowledge;

- Which practices were most important in infection prevention;

- Which educational activities had contributed most to their infection control knowledge.

Practice was assessed after observing six HCAs for two hours each. An observation schedule was adapted from one previously used (Perry and Gore, 1997). This assessed whether hands were decontaminated when required and if a good technique was used.

Knowledge and practice
The HCAs had a good knowledge of when to wash their hands (Table 1). They were also able to identify the correct points at which to do so, when caring for a patient in isolation, to prevent spread of infection. Ninety-seven per cent identified these correctly. Despite this, only 16% knew that a description and visual representation of a good hand-washing technique was incomplete.

The HCAs were aware of the importance of drying hands, with 84% correctly saying that wet hands transfer bacteria more effectively than dry hands.

They generally felt their knowledge of infection control was sufficient, with 22% rating their knowledge as good and 59% as adequate. None of the HCAs rated their knowledge as poor and only 19% felt they needed more knowledge.

This result was interesting in that, although 81% felt their knowledge to be adequate, only 30% considered hand-washing to be of prime importance in infection prevention. More HCAs (46%) felt that knowing which patients had infections was of prime importance, which is contrary to the recommended principle of universal infection control precautions (Department of Health, 1998).

How they performed
During the observations, the mean number of times hands were decontaminated was 8.17 times in the two-hour period (Table 2). During the observation period, individual HCA performance varied from decontaminating hands 10% of the occasions it was required to 93%.

The technique of hand decontamination also varied, with only two HCAs demonstrating good technique every time hands were washed. The lowest percentage of times a good technique was demonstrated was on 69% of occasions (Table 2).

The mean number of times HCAs decontaminated their hands was greater than that noted in a study of registered nurses (Gould, 1994). This may be because of the grade of health care worker. HCAs tend to perform total patient care on one patient before moving to another, whereas registered nurses may have to perform more task-orientated care because of the lack of sufficient registered staff.

The theory-practice gap
During the observations, HCAs made reference to the gap between 'ideal' infection control practice and that practiced at ward level. One noted that a number of new staff had been employed and said 'it was a shame that we didn't teach them before they came on to the ward, as they pick up what other staff do and follow their bad practice'.

Another felt that others learnt from what they saw on the ward and that she had to stop and think whether she had cut any corners because she had to set a good example to nursing students and new HCAs.

To determine whether there was a correlation between the knowledge and practice of the six HCAs, an overall score was calculated for both their knowledge and practice. A positive correlation was found between the questionnaire score-ranking and observations score-ranking. However, because of the small number of subjects participating it was not possible to determine whether this was significant.

Educational influences
Despite the fact that several of the HCAs said they felt that nurses learnt practice from their peers, this was not reflected in how they assessed the educational influences on their infection control knowledge. Attending talks in a classroom setting and receiving verbal information from registered nurses were identified as having the greatest influence on knowledge (Table 3).

This influence of formal education was surprising and is contrary to previously published studies (Morgan, 1996; Courtenay, 1997). The influence of registered nurses, through their ability to provide good verbal information, emphasises the need for all registered nurses to have good infection control knowledge, as well as proficient communication and education skills. The least contribution to knowledge came from reading books and journals.

Conclusion
The sample size in this study was small and therefore care should be taken in the interpretation of these results, which may not be representative of HCAs in other trusts. Although generalised recommendations are not possible, the study has provided insight into the infection control knowledge and practice of HCAs - an area that warrants further study.

Results from the study indicated that existing classroom education of HCAs by infection control nurses, in the research area, should continue. Minor changes were made to the education programme to emphasise the importance of universal infection control precautions and to reiterate the correct technique of hand washing.

With the potential for HCAs to become an increasing proportion of the nursing workforce and to undertake more invasive activities, it is vital that they are well prepared to perform nursing activities safely. More research is needed to determine the optimum approach to HCA education.

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